{"paper_id":"2d714080-2ce2-4f6d-8133-7713f45ebcbc","body_text":"The usefulness of percutaneous bile duct metal stent insertion for malignant biliary obstruction: a retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The usefulness of percutaneous bile duct metal stent insertion for malignant biliary obstruction: a retrospective study Hideki Izumi, Hisamichi Yoshii, Rika Fujino, Shigeya Takeo, Masaya Mukai, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5392450/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Mar, 2025 Read the published version in BMC Gastroenterology → Version 1 posted 13 You are reading this latest preprint version Abstract Background Percutaneous transhepatic bile duct stent insertion is a useful alternative to the endoscopic approach for malignant biliary strictures. This study retrospectively reviewed the cases of percutaneous metallic stent insertion at our institution to evaluate its safety and usefulness. Methods The study included cases of percutaneous bile duct stent insertion performed between April 2016 and August 2024. The causes of biliary strictures and complications were examined. Results The study included 14 cases. Seven patients had pancreatic head cancer, including biliary tract cancer (n = 4) and postoperative gastric cancer (n = 3). The study included three patients who underwent a one-phase insertion. The number of inserted stents tended to increase in patients with postoperative cholangiocarcinoma recurrence. No complication occurred in any patient. Conclusions Percutaneous metal stent insertion is a useful alternative for treating malignant bile duct stenosis that is difficult to approach endoscopically. Percutaneous bile duct metal stent malignant biliary obstruction one-phase insert Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Endoscopic or percutaneous stenting of malignant biliary strictures is a standard technique for relieving jaundice [ 1 ]. Endoscopic bile duct stent insertion is the first-line treatment for most patients with malignant biliary strictures; however, it is rarely possible in patients who have already undergone biliary reconstruction [ 2 , 3 ]. In 2001, a technique for transdigestively draining the biliary tract was reported [ 4 ]. Although this technique is gaining popularity, it is difficult, and not all centers can perform it. Therefore, a percutaneous transhepatic approach may be an effective alternative [ 3 , 5 ]. This study evaluated the use of percutaneous metal stents for malignant biliary strictures that cannot be drained using an endoscopic approach. Material and Methods Patients This study included 14 cases of percutaneous bile duct metal stent insertion performed at Tokai University Hachioji Hospital from April 2016 to August 2024. All patients were cases in which an endoscopic approach was first attempted but could not reach or cannulate the papilla of Vater. This study conformed to the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board of Tokai University in December 2022 (Approval Number 22R-197). Informed consent was obtained from all the participants or their guardians. Written informed consent was obtained from all patients before data release. Technique The procedures were performed under local anesthesia. The bile duct was punctured with a 19G EVS (HAKKO, Japan) under echo guidance. The stenotic site was breached using a RADIFOCUS guide wire M 0.035 (Terumo, Japan) (Fig. 1 ). After replacing the guidewire with an Amplats Super Stiff 0.035 wire (Boston Scientific, USA), an 8-Fr dilator was inserted. An Epic biliary stent (Boston Scientific, USA) was inserted, and the guidewire was removed. In the second-stage procedure, an 8.5-Fr bile drainage catheter (Cook, USA) was placed after dilatation to 9 Fr (Fig. 2 ). A lateral hole is often created in the bile duct to create an internal or an external drainage catheter. An Amplats Super Stiff 0.035 wire (Boston Scientific, USA) was inserted, an Epic biliary stent (Boston Scientific, USA) was inserted (Fig. 3 ), the guidewire was removed, and the procedure was completed (Fig. 4 ). In the two-stage procedure, all catheters were removed after stent insertion. Results All patients (six male and eight female) were Japanese, with a mean age of 66.5 (39–79) years (Table 1 ). Seven patients had pancreatic head cancer, four had postoperative bile duct cancer, and three had postoperative gastric cancer. Either one (n = 9 cases), two (n = 3), or three (n = 3) stents were inserted. Three patients underwent a one-phase insertion. One patient was approached through percutaneous transhepatic gallbladder drainage (PTGBD). No patients developed complications. Table 1 Characteristics of the patients Sex Age (years) Diagnosis Reasons the endoscopic approach failed Number of stents Number of phases M 79 Pancreatic head carcinoma Duodenal stenosis 1 2 F 66 Pancreatic head carcinoma Duodenal stenosis 1 1 M 64 Pancreatic head carcinoma Duodenal stenosis 2 2 F 76 Pancreatic head carcinoma Duodenal stenosis 1 2 F 77 Pancreatic head carcinoma Duodenal stenosis, gastrojejunostomy 1 2 F 71 Pancreatic head carcinoma Not cannulated 1 2 M 62 Pancreatic head carcinoma Postoperative gastric ulcer, Billroth-2 reconstruction 1 2 F 71 Postoperative cholangiocarcinoma, lymph node recurrence Choledochotomy, choledocho-jejunostomy 3 2 F 63 Postoperative cholangiocarcinoma, lymph node recurrence Choledochotomy, choledocho-jejunostomy 1 1 M 57 Postoperative cholangiocarcinoma, lymph node recurrence Choledochotomy, choledocho-jejunostomy 2 2 M 71 Postoperative cholangiocarcinoma, local recurrence Choledochotomy, choledocho-jejunostomy 3 2 M 67 Postoperative gastric carcinoma, lymph node recurrence Total gastrectomy, Roux-en-Y reconstruction 2 2 F 39 Postoperative gastric carcinoma, lymph node recurrence Distal gastrectomy, Billroth-2 reconstruction 1 2 F 68 Postoperative gastric carcinoma, peritoneal dissemination Total gastrectomy, Roux-en-Y reconstruction 1 1 F, female; M, male [Place Table 1 here.] Pancreatic head cancer Seven patients had unresectable pancreatic head cancer. Five of the seven patients had duodenal stenosis, and the papilla of Vater was unreachable. In one patient, the papilla of Vater was reachable, but cannulation was impossible. One patient had a postoperative gastric ulcer and Billroth-2 reconstruction; the papilla of Vater was unreachable. Only one patient had an additional insertion because of stent obstruction: one stent was inserted in a one-phase procedure; the others required two procedures. One case involved stent insertion from a PTGBD via the gallbladder canal (Fig. 1 ). Postoperative cholangiocarcinoma All cholangiocarcinoma cases were postoperative, with bile duct resection and choledochal anastomosis. The causes of obstructive jaundice included lymph node recurrence (n = 3) and local recurrence (n = 1). The papilla of Vater was reachable in one case, but the insertion angle was incorrect, and cannulation was impossible. In the other three cases, the papilla of Vater was unreachable. A stent was inserted in a one-phase procedure in one case. Postoperative gastric cancer All gastric cancer cases included both postoperative and cholangiocarcinoma instances. Two patients underwent total gastrectomy followed by Roux-en-Y reconstruction. One patient underwent Billroth-2 reconstruction. The papilla of Vater was unreachable in all cases. One patient underwent a one-phase procedure. Discussion The expandable metal stent (EMS) was introduced in the late 1980s to overcome the drawbacks of thin and easily clogged plastic stents [ 6 – 8 ]. The EMS is held in the outer sheath of a 3.5–4 mm diameter delivery system, which expands to 8–10 mm in the bile duct after being released from the delivery system. An EMS held in the outer sheath has shown longer patency and lower occlusion rates compared with conventional plastic stents [ 9 – 13 ]. Endoscopic or percutaneous stenting of malignant biliary strictures has become a standard procedure to relieve jaundice [ 1 ]. The transgastrointestinal biliary drainage technique was first reported in 2001 [ 4 ] and has become more widespread. The success and incidence rates of biliary drainage under endoscopic ultrasound were 91.8% and 19.7% in high-volume centers, respectively [ 14 ], compared with 64.7% and 29% in low-volume centers [ 15 ], suggesting that this technique is difficult and not available in all centers. Therefore, a percutaneous transhepatic approach may be an effective alternative [ 3 , 5 ]. In particular, percutaneous transhepatic biliary drainage is best for hilar cholangiocarcinoma with complex stenosis [ 16 – 18 ], suggesting that percutaneous stents may be useful for hilar cholangiocarcinoma. Drainage of > 50% of the liver volume is necessary to be effective [ 19 , 20 ]; however, cholangiocarcinoma often requires multiple stent insertions. This study included two cases of postoperative recurrence of cholangiocarcinoma in which three stents were inserted. Side-by-side techniques are necessary in such cases. Various complications of percutaneous bile duct stenting have been reported, including acute cholangitis, pancreatitis, bleeding, and restenosis [ 21 ]. Pancreatitis is a relatively common complication (0.9–24.2%) [ 22 – 26 ]. Compared with plastic stents, EMSs are more prone to pancreatitis because of their larger diameter and greater dilatation force [ 27 , 28 ]. In particular, when the stent is tipped into the duodenum through the papilla of Vater, its pressure drainage affects the flow of pancreatic juice in the main pancreatic duct, causing pancreatitis [ 29 ]; therefore, caution should be exercised. The pancreatitis incidence after stenting is lower for patients with an already dilated main pancreatic duct [ 22 , 30 ]. Therefore, pancreatitis does not need to be considered in pancreatic cancer. However, EMS insertion for non-pancreatic duct dilatation should be performed with caution because of the high risk of pancreatitis. We have been using bare metal stents for insertion when the main pancreatic duct might be obstructed. We believe the main pancreatic duct is less likely to be obstructed by bare metal stents than by covered stents. In our study, no pancreatitis occurred among 10 patients who underwent bare EMS insertion through the papilla of Vater. A meta-analysis reported no difference in the incidence of pancreatitis between bare and covered metal stents [ 31 ]. Other reports also found no difference in pancreatitis or other complications between bare metal and covered metal stents [ 32 , 33 ], suggesting that the pancreatitis incidence due to stent type should not be a concern. For bile duct stent insertion, obtaining adequate contrast and determining the stenosis length are important. If severe cholangitis develops, drainage should be performed first. Performing another stent insertion is safer once the cholangitis subsides [ 34 ]. In cases of cholangitis due to gallstones, the outcomes and complications of one-phase stone removal in patients with mild or moderate disease are comparable to those of two-phase stone removal [ 35 ]. Therefore, if a patient does not have severe cholangitis, one-phase stent insertion is feasible on the day of drainage. We performed one-phase insertions in three cases without any complications. If possible, one-phase insertion should be performed to free the patient from the needing drainage tubing. This study has some limitations. First, the study was retrospective. Making a simple comparison was difficult because percutaneous insertion was attempted only in cases where endoscopic insertion was impossible. Second, only a few studies from a single institution were available. No significant complications were observed in this study, possibly because of the small number of cases. The number of cases needs to be increased to re-evaluate the usefulness of percutaneous metal stent insertion. In conclusion, percutaneous metal stent insertion is a useful alternative for malignant bile duct stenosis that is difficult to approach endoscopically. The stent can be safely inserted in a one-phase procedure without compromising the patient’s quality of life. Abbreviations EMS, expandable metal stent; PTGBD, percutaneous transhepatic gallbladder drainage Declarations Ethics approval and consent to participate The protocol for this research project was approved by a suitably constituted Ethics Committee of the institution and conformed to the provisions of the Declaration of Helsinki (Committee of Tokai University in December 2022, Approval No 22R-197). Informed consent was obtained from all the participants or their guardians. A copy of the written consent form is available for review by the journal’s Associate Editor. Consent for publication: Written informed consent was obtained from all patients before data release. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: None Author contributions Hideki Izumi performed drainage, stent insertion, clinical follow-up, and data curation, and wrote the original draft. Hisamichi Yoshii performed drainage, stent insertion, and clinical follow-up. Rika Fujino performed drainage, stent insertion, and clinical follow-up. Shigeya Takeo performed drainage, stent insertion, and clinical follow-up. Masaya Mukai supervised the study. Junichi Kaneko supervised the study. Hiroyasu Makuuchi supervised the study. All authors read and approved the final manuscript. Acknowledgments The authors would like to thank Editage for English language proofreading. 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Cite Share Download PDF Status: Published Journal Publication published 31 Mar, 2025 Read the published version in BMC Gastroenterology → Version 1 posted Editorial decision: Revision requested 14 Jan, 2025 Reviews received at journal 13 Jan, 2025 Reviews received at journal 06 Jan, 2025 Reviews received at journal 06 Jan, 2025 Reviewers agreed at journal 06 Jan, 2025 Reviewers agreed at journal 05 Jan, 2025 Reviewers agreed at journal 27 Dec, 2024 Reviewers agreed at journal 24 Dec, 2024 Reviewers invited by journal 07 Dec, 2024 Editor invited by journal 06 Dec, 2024 Editor assigned by journal 17 Nov, 2024 Submission checks completed at journal 17 Nov, 2024 First submitted to journal 05 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5392450\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":391130835,\"identity\":\"916f515b-075b-4aab-8ae4-62c7687df812\",\"order_by\":0,\"name\":\"Hideki 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duct.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5392450/v1/6867dd74a380a8469acbf14c.png\"},{\"id\":71876384,\"identity\":\"3201ab5e-099f-41f5-bcad-0d676bc3d185\",\"added_by\":\"auto\",\"created_at\":\"2024-12-19 10:58:55\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":6418042,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eAn 8.5-Fr bile drainage catheter with a side hole makes an internal/external fistula.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5392450/v1/f1cf14ac1495ac0b663a262c.png\"},{\"id\":71876960,\"identity\":\"42921a94-85e9-4f2e-b6e4-f2c4ce800926\",\"added_by\":\"auto\",\"created_at\":\"2024-12-19 11:06:55\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":7248848,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eAn Amplats Super Stiff 0.035 wire and percutaneous stent are inserted.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5392450/v1/db10404608a8e1ce691e521f.png\"},{\"id\":71876385,\"identity\":\"42fc30d8-20ff-4c2c-bd4e-b1ff8adddd07\",\"added_by\":\"auto\",\"created_at\":\"2024-12-19 10:58:55\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":5948874,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe procedure is complete after the guidewire is removed.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5392450/v1/9fcaff14ff845d929197f070.png\"},{\"id\":80082239,\"identity\":\"41700bf7-2026-493a-bf67-b96d60dd0f3a\",\"added_by\":\"auto\",\"created_at\":\"2025-04-07 16:07:52\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":45828199,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5392450/v1/a2439183-9eb9-406c-80b8-ad30671257d2.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"The usefulness of percutaneous bile duct metal stent insertion for malignant biliary obstruction: a retrospective study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eEndoscopic or percutaneous stenting of malignant biliary strictures is a standard technique for relieving jaundice [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Endoscopic bile duct stent insertion is the first-line treatment for most patients with malignant biliary strictures; however, it is rarely possible in patients who have already undergone biliary reconstruction [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. In 2001, a technique for transdigestively draining the biliary tract was reported [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Although this technique is gaining popularity, it is difficult, and not all centers can perform it. Therefore, a percutaneous transhepatic approach may be an effective alternative [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThis study evaluated the use of percutaneous metal stents for malignant biliary strictures that cannot be drained using an endoscopic approach.\\u003c/p\\u003e\"},{\"header\":\"Material and Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePatients\\u003c/h2\\u003e \\u003cp\\u003eThis study included 14 cases of percutaneous bile duct metal stent insertion performed at Tokai University Hachioji Hospital from April 2016 to August 2024. All patients were cases in which an endoscopic approach was first attempted but could not reach or cannulate the papilla of Vater. This study conformed to the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board of Tokai University in December 2022 (Approval Number 22R-197). Informed consent was obtained from all the participants or their guardians. Written informed consent was obtained from all patients before data release.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eTechnique\\u003c/h3\\u003e\\n\\u003cp\\u003eThe procedures were performed under local anesthesia. The bile duct was punctured with a 19G EVS (HAKKO, Japan) under echo guidance. The stenotic site was breached using a RADIFOCUS guide wire M 0.035 (Terumo, Japan) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). After replacing the guidewire with an Amplats Super Stiff 0.035 wire (Boston Scientific, USA), an 8-Fr dilator was inserted. An Epic biliary stent (Boston Scientific, USA) was inserted, and the guidewire was removed.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn the second-stage procedure, an 8.5-Fr bile drainage catheter (Cook, USA) was placed after dilatation to 9 Fr (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). A lateral hole is often created in the bile duct to create an internal or an external drainage catheter. An Amplats Super Stiff 0.035 wire (Boston Scientific, USA) was inserted, an Epic biliary stent (Boston Scientific, USA) was inserted (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e), the guidewire was removed, and the procedure was completed (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). In the two-stage procedure, all catheters were removed after stent insertion.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eAll patients (six male and eight female) were Japanese, with a mean age of 66.5 (39\\u0026ndash;79) years (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Seven patients had pancreatic head cancer, four had postoperative bile duct cancer, and three had postoperative gastric cancer. Either one (n\\u0026thinsp;=\\u0026thinsp;9 cases), two (n\\u0026thinsp;=\\u0026thinsp;3), or three (n\\u0026thinsp;=\\u0026thinsp;3) stents were inserted. Three patients underwent a one-phase insertion. One patient was approached through percutaneous transhepatic gallbladder drainage (PTGBD). No patients developed complications.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eCharacteristics of the patients\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAge (years)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDiagnosis\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eReasons the endoscopic approach failed\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eNumber of stents\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNumber of phases\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e79\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePancreatic head carcinoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDuodenal stenosis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e66\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePancreatic head carcinoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDuodenal stenosis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e64\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePancreatic head carcinoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDuodenal stenosis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e76\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePancreatic head carcinoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDuodenal stenosis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e77\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePancreatic head carcinoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDuodenal stenosis, gastrojejunostomy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePancreatic head carcinoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eNot cannulated\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e62\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePancreatic head carcinoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePostoperative gastric ulcer, Billroth-2 reconstruction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePostoperative cholangiocarcinoma, lymph node recurrence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCholedochotomy, choledocho-jejunostomy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e63\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePostoperative cholangiocarcinoma, lymph node recurrence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCholedochotomy, choledocho-jejunostomy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e57\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePostoperative cholangiocarcinoma, lymph node recurrence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCholedochotomy, choledocho-jejunostomy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePostoperative cholangiocarcinoma, local recurrence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCholedochotomy, choledocho-jejunostomy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e67\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePostoperative gastric carcinoma, lymph node recurrence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTotal gastrectomy, Roux-en-Y reconstruction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e39\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePostoperative gastric carcinoma, lymph node recurrence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDistal gastrectomy, Billroth-2 reconstruction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e68\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePostoperative gastric carcinoma, peritoneal dissemination\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTotal gastrectomy, Roux-en-Y reconstruction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"6\\\"\\u003eF, female; M, male\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e[Place Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e here.]\\u003c/p\\u003e\\n\\u003ch3\\u003ePancreatic head cancer\\u003c/h3\\u003e\\n\\u003cp\\u003eSeven patients had unresectable pancreatic head cancer. Five of the seven patients had duodenal stenosis, and the papilla of Vater was unreachable. In one patient, the papilla of Vater was reachable, but cannulation was impossible. One patient had a postoperative gastric ulcer and Billroth-2 reconstruction; the papilla of Vater was unreachable. Only one patient had an additional insertion because of stent obstruction: one stent was inserted in a one-phase procedure; the others required two procedures. One case involved stent insertion from a PTGBD via the gallbladder canal (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ch3\\u003ePostoperative cholangiocarcinoma\\u003c/h3\\u003e\\n\\u003cp\\u003eAll cholangiocarcinoma cases were postoperative, with bile duct resection and choledochal anastomosis. The causes of obstructive jaundice included lymph node recurrence (n\\u0026thinsp;=\\u0026thinsp;3) and local recurrence (n\\u0026thinsp;=\\u0026thinsp;1). The papilla of Vater was reachable in one case, but the insertion angle was incorrect, and cannulation was impossible. In the other three cases, the papilla of Vater was unreachable. A stent was inserted in a one-phase procedure in one case.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePostoperative gastric cancer\\u003c/h2\\u003e \\u003cp\\u003eAll gastric cancer cases included both postoperative and cholangiocarcinoma instances. Two patients underwent total gastrectomy followed by Roux-en-Y reconstruction. One patient underwent Billroth-2 reconstruction. The papilla of Vater was unreachable in all cases. One patient underwent a one-phase procedure.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe expandable metal stent (EMS) was introduced in the late 1980s to overcome the drawbacks of thin and easily clogged plastic stents [\\u003cspan additionalcitationids=\\\"CR7\\\" citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. The EMS is held in the outer sheath of a 3.5\\u0026ndash;4 mm diameter delivery system, which expands to 8\\u0026ndash;10 mm in the bile duct after being released from the delivery system. An EMS held in the outer sheath has shown longer patency and lower occlusion rates compared with conventional plastic stents [\\u003cspan additionalcitationids=\\\"CR10 CR11 CR12\\\" citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Endoscopic or percutaneous stenting of malignant biliary strictures has become a standard procedure to relieve jaundice [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. The transgastrointestinal biliary drainage technique was first reported in 2001 [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e] and has become more widespread. The success and incidence rates of biliary drainage under endoscopic ultrasound were 91.8% and 19.7% in high-volume centers, respectively [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e], compared with 64.7% and 29% in low-volume centers [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e], suggesting that this technique is difficult and not available in all centers. Therefore, a percutaneous transhepatic approach may be an effective alternative [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. In particular, percutaneous transhepatic biliary drainage is best for hilar cholangiocarcinoma with complex stenosis [\\u003cspan additionalcitationids=\\\"CR17\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e], suggesting that percutaneous stents may be useful for hilar cholangiocarcinoma. Drainage of \\u0026gt;\\u0026thinsp;50% of the liver volume is necessary to be effective [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]; however, cholangiocarcinoma often requires multiple stent insertions. This study included two cases of postoperative recurrence of cholangiocarcinoma in which three stents were inserted. Side-by-side techniques are necessary in such cases.\\u003c/p\\u003e \\u003cp\\u003eVarious complications of percutaneous bile duct stenting have been reported, including acute cholangitis, pancreatitis, bleeding, and restenosis [\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. Pancreatitis is a relatively common complication (0.9\\u0026ndash;24.2%) [\\u003cspan additionalcitationids=\\\"CR23 CR24 CR25\\\" citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]. Compared with plastic stents, EMSs are more prone to pancreatitis because of their larger diameter and greater dilatation force [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e]. In particular, when the stent is tipped into the duodenum through the papilla of Vater, its pressure drainage affects the flow of pancreatic juice in the main pancreatic duct, causing pancreatitis [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]; therefore, caution should be exercised. The pancreatitis incidence after stenting is lower for patients with an already dilated main pancreatic duct [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]. Therefore, pancreatitis does not need to be considered in pancreatic cancer. However, EMS insertion for non-pancreatic duct dilatation should be performed with caution because of the high risk of pancreatitis. We have been using bare metal stents for insertion when the main pancreatic duct might be obstructed. We believe the main pancreatic duct is less likely to be obstructed by bare metal stents than by covered stents. In our study, no pancreatitis occurred among 10 patients who underwent bare EMS insertion through the papilla of Vater.\\u003c/p\\u003e \\u003cp\\u003eA meta-analysis reported no difference in the incidence of pancreatitis between bare and covered metal stents [\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. Other reports also found no difference in pancreatitis or other complications between bare metal and covered metal stents [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e], suggesting that the pancreatitis incidence due to stent type should not be a concern.\\u003c/p\\u003e \\u003cp\\u003eFor bile duct stent insertion, obtaining adequate contrast and determining the stenosis length are important. If severe cholangitis develops, drainage should be performed first. Performing another stent insertion is safer once the cholangitis subsides [\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e]. In cases of cholangitis due to gallstones, the outcomes and complications of one-phase stone removal in patients with mild or moderate disease are comparable to those of two-phase stone removal [\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. Therefore, if a patient does not have severe cholangitis, one-phase stent insertion is feasible on the day of drainage. We performed one-phase insertions in three cases without any complications. If possible, one-phase insertion should be performed to free the patient from the needing drainage tubing.\\u003c/p\\u003e \\u003cp\\u003eThis study has some limitations. First, the study was retrospective. Making a simple comparison was difficult because percutaneous insertion was attempted only in cases where endoscopic insertion was impossible. Second, only a few studies from a single institution were available. No significant complications were observed in this study, possibly because of the small number of cases. The number of cases needs to be increased to re-evaluate the usefulness of percutaneous metal stent insertion.\\u003c/p\\u003e \\u003cp\\u003eIn conclusion, percutaneous metal stent insertion is a useful alternative for malignant bile duct stenosis that is difficult to approach endoscopically. The stent can be safely inserted in a one-phase procedure without compromising the patient\\u0026rsquo;s quality of life.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eEMS, expandable metal stent; PTGBD, percutaneous transhepatic gallbladder drainage\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe protocol for this research project was approved by a suitably constituted Ethics Committee of the institution and conformed to the provisions of the Declaration of Helsinki (Committee of Tokai University in December 2022, Approval No 22R-197). Informed consent was obtained from all the participants or their guardians. A copy of the written consent form is available for review by the journal’s Associate Editor.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication:\\u0026nbsp;\\u003c/strong\\u003eWritten informed consent was obtained from all patients before data release.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests:\\u0026nbsp;\\u003c/strong\\u003e The authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding:\\u0026nbsp;\\u003c/strong\\u003e None\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eHideki Izumi\\u003c/strong\\u003e performed drainage, stent insertion, clinical follow-up, and data curation, and wrote the original draft.\\u003cstrong\\u003e\\u0026nbsp;Hisamichi Yoshii\\u0026nbsp;\\u003c/strong\\u003eperformed drainage, stent insertion, and clinical follow-up. \\u003cstrong\\u003eRika Fujino\\u0026nbsp;\\u003c/strong\\u003eperformed drainage, stent insertion, and clinical follow-up. \\u003cstrong\\u003eShigeya Takeo\\u0026nbsp;\\u003c/strong\\u003eperformed drainage, stent insertion, and clinical follow-up. \\u003cstrong\\u003eMasaya Mukai\\u003c/strong\\u003e supervised the study. \\u003cstrong\\u003eJunichi Kaneko\\u003c/strong\\u003e supervised the study. \\u003cstrong\\u003eHiroyasu Makuuchi\\u003c/strong\\u003e supervised the study. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors would like to thank Editage for English language proofreading.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eSmith AC, Dowsett JF, Russell RC, Hatfield AR, Cotton PB. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet. 1994;344:1655-60.\\u003c/li\\u003e\\n\\u003cli\\u003eVisrodia KH, Tabibian JH, Baron TH. Endoscopic management of benign biliary strictures. World J Gastrointest Endosc. 2015;7:1003-13.\\u003c/li\\u003e\\n\\u003cli\\u003eK\\u0026ouml;cher M, Cern\\u0026aacute; M, Havl\\u0026iacute;k R, Kr\\u0026aacute;l V, Gryga A, Duda M. Percutaneous treatment of benign bile duct strictures.\\u003cem\\u003e \\u003c/em\\u003eEur J Radiol. 2007;62:170-4.\\u003c/li\\u003e\\n\\u003cli\\u003eGiovannini M, Moutardier V, Pesenti C, Bories E, Lelong B, Delpero JR. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy. 2001;33:898-900.\\u003c/li\\u003e\\n\\u003cli\\u003eBonnel DH, Fingerhut AL. Percutaneous transhepatic balloon dilatation of benign bilioenteric strictures: long-term results in 110 patients. Am J Surg\\u003cem\\u003e. \\u003c/em\\u003e2012;203:675-83.\\u003c/li\\u003e\\n\\u003cli\\u003eIrving JD, Adam A, Dick R, Dondelinger RF, Lunderquist A, Roche A. Gianturco expandable metallic biliary stents: results of a European clinical trial. Radiology. 1989;172:321-6.\\u003c/li\\u003e\\n\\u003cli\\u003eHuibregtse K, Cheng J, Coene PP, Fockens P, Tytgat GN. Endoscopic placement of expandable metal stents for biliary strictures--a preliminary report on experience with 33 patients. Endoscopy. 1989;21:280-2.\\u003c/li\\u003e\\n\\u003cli\\u003eLammer J, Klein GE, Kleinert R, Hausegger K, Einspieler R. Obstructive jaundice: use of expandable metal endoprosthesis for biliary drainage. Work in progress. Radiology. 1990;177:789-92.\\u003c/li\\u003e\\n\\u003cli\\u003eDavids PH, Groen AK, Rauws EA, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet. 1992;340:1488-92.\\u003c/li\\u003e\\n\\u003cli\\u003eKnyrim K, Wagner HJ, Pausch J, Vakil N. A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy. 1993;25:207-12.\\u003c/li\\u003e\\n\\u003cli\\u003eLammer J, Hausegger KA, Fl\\u0026uuml;ckiger F, Winkelbauer FW, Wildling R, Klein GE, et al. Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents. Radiology. 1996;201:167-72.\\u003c/li\\u003e\\n\\u003cli\\u003ePrat F, Chapat O, Ducot B, Ponchon T, Pelletier G, Fritsch J, et al. A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct. Gastrointest Endosc\\u003cem\\u003e. \\u003c/em\\u003e1998;47:1-7.\\u003c/li\\u003e\\n\\u003cli\\u003eHoepffner N, Foerster EC, H\\u0026ouml;gemann B, Domschke W. Long-term experience in Wallstent therapy for malignant choledochal stenosis. Endoscopy. 1994;26:597-602.\\u003c/li\\u003e\\n\\u003cli\\u003eKhashab MA, Messallam AA, Penas I, Nakai Y, Modayil RJ, De la Serna C, et al. International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs. choledochoduodenostomy approaches. Endosc Int Open. 2016;4:E175-81.\\u003c/li\\u003e\\n\\u003cli\\u003eVila JJ, P\\u0026eacute;rez-Miranda M, Vazquez-Sequeiros E, Abadia MAS, P\\u0026eacute;rez-Mill\\u0026aacute;n A, Gonz\\u0026aacute;lez-Huix F, et al. Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey. Gastrointest Endosc. 2012;76:1133-41.\\u003c/li\\u003e\\n\\u003cli\\u003eSaluja SS, Gulati M, Garg PK, Pal H, Pal S, Sahni P, et al. Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment. Clin Gastroenterol Hepatol. 2008;6:944\\u0026ndash;950.e3.\\u003c/li\\u003e\\n\\u003cli\\u003evan Delden OM, Lam\\u0026eacute;ris JS. Percutaneous drainage and stenting for palliation of malignant bile duct obstruction. Eur Radiol\\u003cem\\u003e. \\u003c/em\\u003e2008;18:448-56.\\u003c/li\\u003e\\n\\u003cli\\u003eKloek JJ, van der Gaag NA, Aziz Y, Rauws EAJ, van Delden OM, Lameris JS, et al. Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma. J Gastrointest Surg. 2010;14:119-25.\\u003c/li\\u003e\\n\\u003cli\\u003eVienne A, Hobeika E, Gouya H, Lapidus N, Fritsch J, Choury AD, et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endosc. 2010;72:728-35.\\u003c/li\\u003e\\n\\u003cli\\u003eTakahashi K, Tsuyuguchi T, Saiga A, Horikoshi T, Ooka Y, Sugiyama H, et al. Risk factors of ineffective drainage in uncovered self-expandable metal stenting for unresectable malignant hilar biliary strictures. Oncotarget. 2018;9:28185-94.\\u003c/li\\u003e\\n\\u003cli\\u003eChandrashekhara SH, Gamanagatti S, Singh A, Bhatnagar S. Current status of percutaneous transhepatic biliary drainage in palliation of malignant obstructive jaundice: a review. Indian J Palliat Care\\u003cem\\u003e. \\u003c/em\\u003e2016;22:378-87.\\u003c/li\\u003e\\n\\u003cli\\u003eSugawara S, Arai Y, Sone M, Katai H. Frequency, severity, and risk factors for acute pancreatitis after percutaneous transhepatic biliary stent placement across the papilla of Vater. Cardiovasc Intervent Radiol\\u003cem\\u003e. \\u003c/em\\u003e2017;40:1904-10.\\u003c/li\\u003e\\n\\u003cli\\u003eKim ET, Gwon DI, Kim JW, Ko GY. Acute pancreatitis after percutaneous insertion of metallic biliary stents in patients with unresectable pancreatic cancer. Clin Radiol\\u003cem\\u003e. \\u003c/em\\u003e2020;75:57-63.\\u003c/li\\u003e\\n\\u003cli\\u003eYang Y, Liu RB, Liu Y, Jiang HJ. Incidence and risk factors of pancreatitis in obstructive jaundice patients after percutaneous placement of self-expandable metallic stents. Hepatobiliary Pancreat Dis Int. 2020;19:473-7.\\u003c/li\\u003e\\n\\u003cli\\u003eWilcox CM, Phadnis M, Varadarajulu S. Biliary stent placement is associated with post-ERCP pancreatitis. Gastrointest Endosc\\u003cem\\u003e. \\u003c/em\\u003e2010;72:546-50.\\u003c/li\\u003e\\n\\u003cli\\u003ePranculis A, Kievi\\u0026scaron;as M, Kievi\\u0026scaron;ienė L, Vaičius A, Vanagas T, Kaupas RS, et al. Percutaneous transhepatic biliary stenting with uncovered self-expandable metallic stents in patients with malignant biliary obstruction \\u0026ndash; efficacy and survival analysis. Pol J Radiol. 2017;82:431-40.\\u003c/li\\u003e\\n\\u003cli\\u003eShin SH, So H, Cho S, Kim N, Baik GH, Lee SK, et al. The number of wire placement in the pancreatic duct and metal biliary stent as risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis. J Gastroenterol Hepatol\\u003cem\\u003e. \\u003c/em\\u003e2020;35:1201-7.\\u003c/li\\u003e\\n\\u003cli\\u003eKim GH, Ryoo SK, Park JK, Park JK, Lee KH, Lee KT, et al. Risk factors for pancreatitis and cholecystitis after endoscopic biliary stenting in patients with malignant extrahepatic bile duct obstruction. Clin Endosc. 2019;52:598-605.\\u003c/li\\u003e\\n\\u003cli\\u003eItoi T, Tsuchiya T, Tanaka R, Ikeuchi N, Sofuni A. Lethal post-endoscopic retrograde cholangiopancreatography pancreatitis following fully covered metal stent placement in distal biliary obstruction due to unresectable cholangiocarcinoma. Dig Endosc. 2013;25;Suppl 2:117-21.\\u003c/li\\u003e\\n\\u003cli\\u003eMartinez NS, Inamdar S, Firoozan SN, Izard S, Lee C, Benias PC, et al. Evaluation of post-ERCP pancreatitis after biliary stenting with self-expandable metal stents vs. plastic stents in benign and malignant obstructions. Endosc Int Open\\u003cem\\u003e. \\u003c/em\\u003e2021;9:E888\\u0026ndash;94.\\u003c/li\\u003e\\n\\u003cli\\u003eAlmadi MA, Barkun AN, Martel M. No benefit of covered vs uncovered self-expandable metal stents in patients with malignant distal biliary obstruction: a meta-analysis. Clin Gastroenterol Hepatol\\u003cem\\u003e. \\u003c/em\\u003e2013;11:27\\u0026ndash;37.e1.\\u003c/li\\u003e\\n\\u003cli\\u003ePark SW, Lee KJ, Chung MJ, Jo JH, Lee HS, Park JY, et al. Covered versus uncovered double bare self-expandable metal stent for palliation of unresectable extrahepatic malignant biliary obstruction: a randomized controlled multicenter trial. Gastrointest Endosc\\u003cem\\u003e. \\u003c/em\\u003e2023;97:132\\u0026ndash;142.e2.\\u003c/li\\u003e\\n\\u003cli\\u003eLee HJ, Chung MJ, Park JY, Park SW, Nam CM, Song SY, et al. A prospective randomized study for efficacy of an uncovered double bare metal stent compared to a single bare metal stent in malignant biliary obstruction. Surg Endosc. 2017;31:3159-67.\\u003c/li\\u003e\\n\\u003cli\\u003eMiura F, Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gouma DJ, et al. TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobil Pancreat Sci. 2013;20:47-54.\\u003c/li\\u003e\\n\\u003cli\\u003eEto K, Kawakami H, Haba S, Yamato H, Okuda T, Yane K, et al. Single-stage endoscopic treatment for mild to moderate acute cholangitis associated with choledocholithiasis: a multicenter, non-randomized, open-label and exploratory clinical trial. J Hepatobil Pancreat Sci. 2015;22:825-30.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-gastroenterology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bmge\",\"sideBox\":\"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bmge/default.aspx\",\"title\":\"BMC Gastroenterology\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Percutaneous bile duct metal stent, malignant biliary obstruction, one-phase insert\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5392450/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5392450/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003ePercutaneous transhepatic bile duct stent insertion is a useful alternative to the endoscopic approach for malignant biliary strictures. This study retrospectively reviewed the cases of percutaneous metallic stent insertion at our institution to evaluate its safety and usefulness.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eThe study included cases of percutaneous bile duct stent insertion performed between April 2016 and August 2024. The causes of biliary strictures and complications were examined.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eThe study included 14 cases. Seven patients had pancreatic head cancer, including biliary tract cancer (n\\u0026thinsp;=\\u0026thinsp;4) and postoperative gastric cancer (n\\u0026thinsp;=\\u0026thinsp;3). The study included three patients who underwent a one-phase insertion. The number of inserted stents tended to increase in patients with postoperative cholangiocarcinoma recurrence. No complication occurred in any patient.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003ePercutaneous metal stent insertion is a useful alternative for treating malignant bile duct stenosis that is difficult to approach endoscopically.\\u003c/p\\u003e\",\"manuscriptTitle\":\"The usefulness of percutaneous bile duct metal stent insertion for malignant biliary obstruction: a retrospective study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-12-19 10:58:50\",\"doi\":\"10.21203/rs.3.rs-5392450/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-01-14T06:37:45+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-01-13T07:55:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-01-06T22:51:55+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-01-06T17:04:35+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"280424161354097490079977486071081083207\",\"date\":\"2025-01-06T16:17:58+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"128388506846601506621432606650230708234\",\"date\":\"2025-01-05T23:22:57+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"145930421697383900932935854789848380635\",\"date\":\"2024-12-27T22:35:30+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"310216533094195028046409176773611693345\",\"date\":\"2024-12-24T11:27:45+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2024-12-08T01:47:58+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2024-12-06T09:00:40+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-11-18T03:53:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-11-18T03:52:41+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Gastroenterology\",\"date\":\"2024-11-05T05:49:09+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-gastroenterology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bmge\",\"sideBox\":\"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bmge/default.aspx\",\"title\":\"BMC Gastroenterology\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"0e711f22-50e7-4e36-a7b2-22873c8ad602\",\"owner\":[],\"postedDate\":\"December 19th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-04-07T16:03:23+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-5392450\",\"link\":\"https://doi.org/10.1186/s12876-025-03767-5\",\"journal\":{\"identity\":\"bmc-gastroenterology\",\"isVorOnly\":false,\"title\":\"BMC Gastroenterology\"},\"publishedOn\":\"2025-03-31 15:57:14\",\"publishedOnDateReadable\":\"March 31st, 2025\"},\"versionCreatedAt\":\"2024-12-19 10:58:50\",\"video\":\"\",\"vorDoi\":\"10.1186/s12876-025-03767-5\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12876-025-03767-5\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5392450\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5392450\",\"identity\":\"rs-5392450\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}